Use of depot antipsychotic medications for medication nonadherence in schizophrenia

Cost-effectiveness of olanzapine long-acting injection in the treatment of patients with schizophrenia in the United States: a micro-simulation economic decision model

OBJECTIVE

To compare, from the perspective of third-party payers in the United States health care system, the cost-effectiveness of olanzapine long-acting injection (LAI, depot) with alternative antipsychotic agents including risperidone-LAI, paliperidone-LAI, haloperidol-LAI, and oral olanzapine, in the treatment of patients with schizophrenia who have been non-adherent or partially adherent with oral antipsychotics.

RESEARCH DESIGN AND METHODS

A 1-year micro-simulation economic decision model was developed to simulate the dynamics of usual care of patients with schizophrenia who continue, discontinue, switch, or restart their medication. The model uses a range of clinical and cost parameters including adherence levels, relapse with and without hospitalization, quality-adjusted life years (QALYs), treatment discontinuation rates by reason, treatment-emergent adverse events, suicide, health care resource utilization, and direct health care costs. Published medical literature and a clinical expert panel were used to develop baseline model assumptions.

OUTCOME MEASURES

Key model outputs include annual total direct cost (US$) per treatment and incremental cost-effectiveness values per additional QALY gained.

RESULTS

Model results found that the olanzapine-LAI treatment strategy was more effective (greater QALYs) and less costly than risperidone-LAI, paliperidone-LAI, and haloperidol-LAI. In addition, olanzapine-LAI was both more effective and more costly, with an estimated incremental cost/QALY of $26,824 compared to oral olanzapine. The base-case and multiple sensitivity analyses found olanzapine-LAI to remain within acceptable cost-effective ranges (<$50,000) in terms of incremental cost/QALY gained.

CONCLUSIONS

This micro-simulation model finds the olanzapine-LAI treatment strategy to result in better effectiveness and to be a cost-effective alternative compared to oral olanzapine and the LAI formulations of risperidone, paliperidone, and haloperidol in the treatment of non-adherent and partially adherent patients with schizophrenia in the United States. A key limitation is the assumption how LAI therapies compare to oral counterparts due to sparse head-to-head data. Further research is needed to verify baseline assumptions.

Treatment patterns and health care resource utilization in a 1-year observational cohort study of outpatients with schizophrenia at risk of nonadherence treated with long-acting injectable antipsychotics

PURPOSE

To describe (1) the clinical profiles and the patterns of use of long-acting injectable (LAI) antipsychotics in patients with schizophrenia at risk of nonadherence with oral antipsychotics, and in those who started treatment with LAI antipsychotics, (2) health care resource utilization and associated costs.

PATIENTS AND METHODS

A total of 597 outpatients with schizophrenia at risk of nonadherence, according to the psychiatrist's clinical judgment, were recruited at 59 centers in a noninterventional prospective observational study of 1-year follow-up when their treatment was modified. In a post hoc analysis, the profiles of patients starting LAI or continuing with oral antipsychotics were described, and descriptive analyses of treatments, health resource utilization, and direct costs were performed in those who started an LAI antipsychotic.

RESULTS

Therapy modifications involved the antipsychotic medications in 84.8% of patients, mostly because of insufficient efficacy of prior regimen. Ninety-two (15.4%) patients started an LAI antipsychotic at recruitment. Of these, only 13 (14.1%) were prescribed with first-generation antipsychotics. During 1 year, 16.3% of patients who started and 14.9% of patients who did not start an LAI antipsychotic at recruitment relapsed, contrasting with the 20.9% who had been hospitalized only within the prior 6 months. After 1 year, 74.3% of patients who started an LAI antipsychotic continued concomitant treatment with oral antipsychotics. The mean (median) total direct health care cost per patient per month during the study year among the patients starting any LAI antipsychotic at baseline was €1,407 (€897.7). Medication costs (including oral and LAI antipsychotics and concomitant medication) represented almost 44%, whereas nonmedication costs accounted for more than 55% of the mean total direct health care costs.

CONCLUSION

LAI antipsychotics were infrequently prescribed in spite of a psychiatrist-perceived risk of nonadherence to oral antipsychotics. Mean medication costs were lower than nonmedication costs.

Baseline characteristics and initial treatment decisions for patients with schizophrenia at risk of treatment nonadherence

In this year-long, prospective observational study, sociodemographic, clinical, and functional characteristics were assessed in outpatients with schizophrenia from Australia, Mexico, Romania, and Taiwan who were switched from their primary oral antipsychotic to another oral or depot antipsychotic at study entry because of physician-perceived nonadherence risks. Patients (N = 406) rated their quality of life and functioning level as low. Few patients (10.6%, 43/406) were switched to depot antipsychotics, with country-specific differences (P < 0.001). Although illness severity was similar between subgroups, the depot switch subgroup had: a documented history of nonadherence (32.6% versus oral: 4.7%); recent alcohol (48.8% versus 23.2%; P < 0.001) or illicit drug use (16.3% versus 5.0%; P = 0.010); recent depot antipsychotic (20.7% versus 7.5%; P = 0.030) and mood stabilizer use (51.7% versus 26.3%; P = 0.008); poorer attitudes towards medication (P = 0.004); and poorer illness awareness (P = 0.041). Findings indicate that even when a risk of nonadherence has been identified, few patients with schizophrenia receive depot antipsychotics, despite being prime candidates for depot therapy. Findings suggest physicians may select depot therapy based on previous nonadherence, substance use, recent depot antipsychotic and mood stabilizer use, poor attitudes towards medications, and poor illness awareness.

Antipsychotic long-acting injections: prescribing practice in the UK

BACKGROUND

Data from the USA, Australia and Europe suggest that the proportion of patients with schizophrenia prescribed an antipsychotic long-acting injection (LAI) varies from around a quarter to a third. Use of LAIs has been associated with male gender and younger age.

AIMS

To characterise the use of LAIs in people with schizophrenia in three clinical settings in the UK.

METHOD

The study used audit data from quality improvement programmes conducted by the Prescribing Observatory for Mental Health.

RESULTS

Long-acting injections were found to be prescribed for between a quarter and a third of patients, depending on the clinical setting. Flupentixol, risperidone and zuclopenthixol were most commonly prescribed and were combined with an oral antipsychotic in half of cases, frequently constituting high-dose prescribing. The use of LAIs was not consistently associated with age, gender or ethnicity.

CONCLUSIONS

Antipsychotic LAIs are commonly prescribed. We did not replicate previous findings with respect to demographic variables associated with their use.

Differences in the primary care management of patients with psychosis from two ethnic groups: a population-based cross-sectional study

BACKGROUND

Ethnicity is an important dimension in many aspects of psychosis.

OBJECTIVE

To investigate ethnic differences in the primary care management of patients with psychosis.

METHODS

Data were obtained from Lambeth DataNet, a database of computerized general practice case records derived from practices in an inner city London borough. We undertook a cross-sectional survey of patients with psychosis.

OUTCOME MEASURES

health screening, chronic disease management and prescribing data and differences between ethnic groups were expressed as odds ratios (ORs).

RESULTS

One thousand six hundred and ninety-four of 165,911 (1.02%) registered patients had a diagnosis of psychosis; 1090 (64%) had ethnicity recorded; 501 were White and 403 were Black or Black British. There were no significant ethnic differences for blood pressure, cholesterol or HbA1c monitoring or control; cervical or mammography screening; treatment with hypotensives, statins, antidepressants, lithium, antipsychotics or atypical antipsychotics. Depot injectable antipsychotics were more likely to be prescribed to Black patients than other delivery modes: OR 2.10 (95% CI: 1.20-3.67).

CONCLUSIONS

Measurable aspects of physical health care of patients with psychosis were similar, regardless of ethnicity. Increased use of the depot antipsychotic medication in black patients needs further exploration.

Assessing the infrequent oral supplementation of olanzapine long-acting injection in the treatment of schizophrenia

OBJECTIVE

Adding another antipsychotic to a treatment regimen was previously used in evaluating the medication's efficacy. Supplementation of depot antipsychotics with oral antipsychotics is particularly meaningful because depot formulations are typically chosen for patients struggling with adherence to oral antipsychotics. This post-hoc analysis assessed supplementation of olanzapine long-acting injection (olanzapine-LAI) with oral olanzapine.

SUBJECTS AND METHODS

We used 12 months of data from an open-label, single-arm extension study of patients with schizophrenia or schizoaffective disorder (N=931) treated with olanzapine-LAI. The prevalence, duration, time to first supplementation, and best predictors of oral supplementation were assessed.

RESULTS

Oral supplementation occurred in 21% of patients for a median of 31 days with mean modal dose of 10.8 mg/day. Mean time to first supplementation was shorter for patients who were at least moderately ill at baseline compared to less ill patients (47 vs. 97 days, p<0.001). Best predictors of oral supplementation included a more severe illness profile at baseline, lower olanzapine-LAI dose prior to oral supplementation, supervised living arrangements, and being African-American.

CONCLUSION

Supplementation of olanzapine-LAI appears to be infrequent, of relatively short duration, and reserved for more severely ill patients who may require a targeted rescue medication due to signs of impending relapse.

Duration of pharmacotherapy with long-acting injectable risperidone in the treatment of schizophrenia

Although long-acting injectable risperidone (LAIR) has been hypothesized to improve medication adherence compared to oral medications, data from real-world practice have yet to be presented on time to treatment discontinuation. Records of all new prescriptions for antipsychotic medication during the first 2 months of FY 2006 for VA patients diagnosed with schizophrenia (N = 11,821) were examined and duration of treatment with LAIR and oral antipsychotics were calculated for the next 2 years. Multivariable logistic regression was used to identify patient characteristics independently associated with receipt of LAIR. Proportional hazards models were used to compare the likelihood of discontinuing each of the medications as compared to LAIR. Altogether, 2.4% of the 11,821 new starts were prescribed LAIR, 44.6% of whom continued therapy for 540-720 days (18-24 months), less than the 77.1% of those on clozapine, 57.9% on oral conventional antipsychotics, 55.0% on olanzapine, and 49.5% on risperidone, but more than the 27.7% on aripiprazole. After adjusting for potentially confounding factors, patients who were initiated on LAIR were more likely to discontinue their medication than those who were initiated on oral first- or second-generation antipsychotics (SGAs) with the exception ziprasidone and aripiprazole. Less than half of patients on LAIR continued treatment for 18 months, a smaller proportion than of those started on most oral first- or second-generation antipsychotics, suggesting that for many patients with schizophrenia improved adherence from this treatment may not be sustained.

Treatment patterns and clinical characteristics prior to initiating depot typical antipsychotics for nonadherent schizophrenia patients

BACKGROUND

Nonadherence with antipsychotic medication is an important clinical and economic problem in the treatment of schizophrenia. This study identified treatment patterns and clinical characteristics that immediately precede the initiation of depot typical antipsychotics in the usual treatment of schizophrenia patients with a recent history of nonadherence with oral antipsychotic regimens.

METHODS

Data were drawn from a large, multisite, 3-year prospective noninterventional observational study of persons treated for schizophrenia in the United States, which was conducted between 7/1997 and 9/2003. The analytical sample included patients who, in the 6 months prior to enrollment, were considered nonadherent with oral antipsychotics and were not treated with depot antipsychotics (N = 314). Patients who were subsequently initiated on typical depots during the 3-year follow-up were compared with patients who continued therapy with only oral antipsychotic agents. Group comparisons were made on patient baseline characteristics and precedent variables that were assessed 1 to 6 months prior to depot initiation. Patient assessments were made at predetermined intervals throughout the 3-year study using standard psychiatric measures, a patient-reported questionnaire, and medical record information.

RESULTS

A small proportion of patients (12.4%) who were recently nonadherent with oral antipsychotics were subsequently initiated on depot therapy during the 3-year study. Compared to patients treated with only oral antipsychotics, those subsequently initiated on a depot were significantly more likely to be hospitalized at depot initiation or the previous 30 days, to have recent involvement with the criminal justice system (arrests), recent illicit drug use, recent switching or augmentation of oral antipsychotics, and recent treatment with oral typical antipsychotics.

CONCLUSION

Despite prior nonadherence with oral antipsychotic medication, only a small proportion of nonadherent schizophrenia patients were initiated on depot antipsychotics in this 3-year prospective study. Patients subsequently initiated on depot had a more severe treatment pattern and clinical profile immediately preceding depot initiation. This profile may have triggered the decision to initiate a depot. Findings have important clinical and economic ramifications for practitioners, policy makers, and other decision makers, highlighting the need for early identification of and tailored therapeutics for schizophrenia patients with a history of nonadherence with their recent oral antipsychotic regimens.

Identifying the profile of optimal candidates for antipsychotic depot therapy A cluster analysis

OBJECTIVE

The prescription rate of antipsychotic depots for patients suffering from schizophrenia is currently low. Among these patients the assumable acceptance rate of depot as treatment of choice is markedly higher, but psychiatrists do report that patients frequently reject the offer of depot treatment. In a first step to highlight this contradiction we aimed at identifying attributes of patients that indicate their qualification for depot treatment in the eyes of the psychiatrists.

METHOD

We surveyed 201 psychiatrists about their evaluation of patients' attributes potentially influencing their qualification for depot treatment. Multidimensional and cluster analyses were applied to detect associated attributes. A second sample of further 248 psychiatrists was asked about their proposal of depot treatment to patients depending on the number of relapses in the past.

RESULTS

Two clusters of attributes were identified characterizing patients' qualification for depot treatment. In cluster I episodes of non-compliance and relapses in the past were considered as favoring the qualification. cluster II included a high level of insight, openness to drug treatment and profound knowledge about the disease representing attributes that increase patients' qualification. Patients were significantly more likely to be offered depot treatment after their fourth reexacerbation compared to their first relapse.

CONCLUSIONS

Attributes comprised in cluster I highly qualify a patient for depot treatment which is in line with the current prescription stereotype. This conservative notion of depot use is supplemented by an alternative cluster II patient profile. Patients fitting this cluster also potentially qualify for depot treatment according to the surveyed psychiatrists and should be offered depot in clinical routine considering the advantages of this form of administration.